SUSTAINING ADVOCACY FOR ICPD AGENDA IN HEALTH REFORMS UNDER REGIME CHANGE: LESSONS FROM BANGLADESH ROUNAQ JAHAN COLUM

1. SUSTAINING ADVOCACY FOR ICPD AGENDA IN HEALTH REFORMS UNDER REGIME CHANGE: LESSONS FROM BANGLADESHROUNAQ JAHANCOLUMBIA UNIVERSITY

2. 2 A case study of how changes in government shift policy commitment to health sector reforms (HSR) and ICPD agenda.

3. Study based on Columbia University-IWHC collaborative project on HSR in Bangladesh Data sources included: documents and interviews with key informants; consultations with community based Health Watch Groups; author�s own personal notes as a member of the World Bank led team negotiating reforms during 1996-1998.

4. Bangladesh adopted its first Health and Population Sector Strategy (HPSS) in 1996 and a five year national Health and Population Sector Programme (HPSP) in 1998. .

5. 5 HPSS/HPSP introduced major health sector reforms: sector wide programming; integrated service delivery through unification of health and family planning services; community and stakeholder participation; decentralization and autonomy; public-private-NGO partnership.

6. 6 Key elements of ICPD agenda were adopted. Goal to improve health of vulnerable women, children and poor. Client-centered Essential Services Package (ESP) delivered through the primary health care system. ESP to include comprehensive Sexual and Reproductive Health (SRH) and 60 to 70 % of budget.

7. 7 SRH integrated through unification of health and family planning services. Poor women to participate in policy/program. Gender issues mainstreamed.

8. 8 HPSS/HPSP marked major departures in health programming. Communities and stakeholders consulted. Civil society included in policy dialogues. Population control agenda of reproductive health dropped. Prioritization of maternal health.

9. 9 Family Planning (FP) to shift attention to both men and women. Side effects of contraceptives recognized. Violence against women treated as a public health issue. RTI/STI, adolescent health, safe abortion services taken into account.

10. 10 HSR in Bangladesh a massive effort. Restructuring of a national program of approximately 3 billion. Changing the service rules and training of the Ministry of Health and Family Welfare (MOHFW).

11. 11 Government of Bangladesh (GOB) reached a consensus with the donors on major reform elements in 1995 when it was led by the Bangladesh Nationalist Party (BNP).

12. 12 The reform design survived a regime change in 1996 when the Awami League (AL) came to power and adopted HPSS and HPSP.

13. 13 Opponents of reforms however took advantage of the next change of government in 2001 from AL to BNP and reversed decision on one key element�unification of Health and Family Planning.

14. 14 The current government is again prioritizing FP. Policy reversal on unification justified on grounds of deteriorating morale of FP causing stagnation in TFR and CPR. Maternal health strategy approved in 2001 not yet implemented. Allocation for maternal health reduced.

15. 15 Implementation of HPSP stalled and GOB-donor dialogue deadlocked since 2001.

16. 16 Questions addressed in the paper Why and how did the reform design adopt the ICPD agenda? Why and how did the policy commitment to one key element�integration of health and family planning services�change?

17. 17 Why and how did HPSS/HPSP adopt the ICPD agenda?

18. 18 The participatory process of HPSS/HPSP formulation enabled alliance building of ICPD advocates from civil society, donors and government to work on the design issues.

19. 19 The four important mechanisms for developing HPSS/HPSP were: World Bank led preparatory missions; 17 task forces set up by the government with tripartite membership from government, donors and civil society; log frame workshops on program design; nationwide consultations with communities and stakeholders.

20. 20 Preparatory missions set the agenda of negotiations.--International consultants in preparatory missions facilitated the participation of Bangladeshi civil society advocates.

21. 21 Task Forces and log frame workshops elaborated technical design issues. SRH advocates from donor agencies in partnership with GOB and Bangladeshi civil society pushed the ICPD agenda. Costing of the ESP package critical for comprehensive SRH.

22. 22 Community and stakeholder consultations carried over two years: validated the ICPD agenda; created transparency; facilitated consensus-building.

23. 23 Consultations organized in a GOB-donor-NGO partnership. Village level consultations with service users and providers using PRA in 5 regions. District level workshops with service users and other stakeholders in 10 regions. National level GOB-NGO public dialogue with media participation.

24. 24 Consultations revealed consensus on: delivery of comprehensive SRH as part of ESP; improving availability and quality of services; improving management and coordination; establishing transparency and accountability; building partnership with communities and other stakeholders; decentralization.

25. 25 Consultations indicated lack of consensus on services unification.

26. 26 The health officials favored unification on grounds of improving efficiency and avoiding duplication. The FP officials opposed unification on grounds of loss of status and morale leading to deterioration of services. Female services users preferred integrated SRH from one stop center. But the main concern was getting quality services.

27. 27 Unification decision supported by: donors; civil society; powerful professional groups such as the Bangladesh Medical Association.

28. The final decision on unification taken by the Secretary, MOHFW and the Prime Minister.

29. 29 The design of reforms initially driven by donors but GOB and civil society on board after two years of consultation.--GOB took ownership of reforms and drafted HPSP without foreign consultants.

30. 30 Why and how did the policy commitment to unification of health and family planning change?

31. 31 GOB unified Health and FP in stages: Lower levels unified by early 2000. Higher levels remained bi-furcated till 2001. Government approval of higher level unification secured before 2001 election but never implemented.

32. 32 In 2001 after the change of AL government, an opponent of unification became Secretary, MOHFW and succeeded in securing support of top political leadership.

33. 33 Civil society remained silent on this reversal while donors protested against it.

34. 34 GOB�s policy reversal on unification facilitated by lack of information on gains and shortfalls of HPSP. Gains: Reducing maternal mortality Improving ANC Increasing skilled birth attendants Reducing severe malnutrition, infant and child mortality Shortfalls: Stagnation in TFR and CPR Lack of improvement in access and service quality Erosion of national ownership Lack of transparency and accountability

35. 35 GOB and donors neglected to engage civil society and promote public accountability The FP lobby used data on TFR and CPR to argue in favor of reverting back to vertical FP services. The supporters of unification failed to counter the FP lobby through public dialogue on achievements and limitations of HPSP.

36. 36 Civil society advocates ignored during implementation uninformed and uninvolved about the government-donor contestations over HPSP and next health program.

37. 37 Lessons to sustain advocacy for ICPD under regime change

38. 38 Advocacy for ICPD best sustained by autonomous civil society organizations whose commitment will not change with shifting election results.

39. 39 Civil society advocates need to: be informed by evidence and analysis of implementation experiences; build alliances with researchers, professionals, community based groups and the women�s movement; pro-actively involve media.

40. 40 The government needs to: institutionalize partnership and dialogue with civil society; ensure transparency and accountability.

41. 41 Donors need to: Support civil society advocacy organizations and not simply service NGOs. Promote independent assessment of policies and programs.